States present lethal injections as a quasi-medical way of
executing the condemned. New Jersey law goes so far as to refer to the lethal
chemicals as execution medications.174 But executions are not medical
procedures, and professional ethics prohibit doctors from participating in
them. Indeed, it was the growing practice of lethal injection executions that
prompted the medical community to clarify and solidify its position that
physician participation in executions violates the ethical precepts of the
profession.

The prohibition against physician participation in
executions is rooted in the medical ethics of a profession committed to the
principles of non-malfeasance (the avoidance of causing harm) and beneficence
(the affirmative provision of good).175 The American Medical Associations Code
of Ethics states: A physician, as a member of a profession dedicated to
preserving life when there is hope of doing so, should not be a participant in
a legally authorized execution.176
The AMA defines the prohibited participation to include monitoring vital signs,
attending or observing as a physician, rendering technical advice regarding
executions, selecting injection sites, starting intravenous lines; prescribing,
preparing, administering or supervising the injection of drugs; inspecting or
testing lethal injection devices; and consulting with or supervising lethal
injection personnel. Under the AMA Code, the only permissible participation by
a physician in an execution would be to provide a sedative to a prisoner upon
his request prior to his execution and to certify the prisoners death after
another person has pronounced it.177
The code of ethics for the Society of Correctional Physicians states: The
correctional health professional shall not be involved in any aspect of
execution of the death penalty.178
The American Nurses Association has adopted a similar provision, stating: When
the health care professionalserves in an execution under
circumstances that mimic care, thehealing purposes of health
services and technology become distorted.179

Despite medical ethics, twenty-eight states require a
physician to determine or pronounce death during an execution.180 Nine states require the
presence of a physician without indicating the purpose of the physicians
presence.181
One can only surmise that medical expertise is desired by those states to
ensure that the execution runs smoothly, i.e., to respond in case something
goes awry, or to pronounce death.182
Some state rules call specifically for a more direct role for physicians. For
example, in Oregon, departmental procedures specify that the physician will be
responsible for observing the execution process and examining the condemned
after the lethal substance(s) has been administered to ensure that death is
induced.183
California regulations require physicians to fit the heart monitor to the
condemned inmate and to monitor the inmates heart. In Oklahoma, the original
protocol devised by Chapman required a physician to inspect the catheter and
monitoring equipment and to make certain the fluid would flow into the inmates
vein. That provision is not present, however, in the current Oklahoma protocol.184

Physicians have, in fact, participated directly in the
execution process itself. In 1990, three physicians administered the first
lethal injection execution in Illinois.185 For a number of years, anesthesiologists
injected the drugs in Arizonas lethal injection executions, although that
function is no longer undertaken by a doctor.186 During Texass first lethal injection execution, Dr. Ralph Gray, the state prison medical
director, was present, along with Dr. Bascom Bentley, a physician in private
practice, to pronounce the prisoners death. They watched as execution team
members struggled to find intravenous access.187 Eventually, the team
convinced Gray to examine the prisoner and point out the best injection site.188 Gray
had also watched the warden mix the chemical agents. When the warden tried to
push them through the syringe, he saw that because the warden had accidentally
mixed all the chemical agents together, they had precipitated into a clot of
white sludge.189
When Gray went to pronounce the prisoner dead, he found the prisoner was still
alive. Gray and Bentley suggested allowing more time for the drugs to
circulate.190

More recently, a physician, who requested that his name and
state remain anonymous, described three lethal injection executions where the
execution technicians were having a hard time finding a vein to establish an
intravenous line, because the prisoners were obese or had a past history of
intravenous drug use, or both.191
Although present to monitor the EKG machine and pronounce death, the physician
was called upon to help establish an intravenous line after the technicians had
tried to do so for thirty minutes without success.192 During another
execution in which the technicians could not find a vein, the physician also
could not, and, in the end, he needed to place a central linea complex and
highly technical procedure which involves inserting the catheter in one of the
deep large veins in the groin, chest, or neck.193

As the above examples suggest, executions can and do go
awry, and it is not clear what would happen sometimes if physicians were not
present. As one doctor who has certified the deaths of executed inmates noted,
If the doctors and nurses are removed, I dont think [lethal injection] could
be competently or predictably done.194

Although there are exceptions, there is strong resistance in
the medical profession to directly contributing to the success of an
execution. Even doctors who work for correctional agencies have refused to
participate in executions, sometimes at considerable professional cost.195 In Colorado, for example, the medical staff at the Department of Corrections refused to have
anything to do with the executions, which is why the state uses EMTs to insert
the catheter and inject the drugs.196

Human Rights Watch recognizes that the ethical prohibition
on physician participation in executions limits the way states can conduct
lethal injection executions. This is a dilemma of the states makingby their
refusal to abolish capital punishmentand it is a dilemma states must resolve
if they continue to use lethal injection executions. For example, alternative
methods of lethal injection have been suggested that would negate the need for
anesthesiologists to monitor levels of unconsciousness. Some states are
considering legislation to prevent physician liability for participating in
executions in breach of medical ethics, in the hopes this will facilitate their
participation in executions.197
It is up to state legislators and corrections agencies to determine how to
proceed, but they must do so respecting the human rights injunction to use the
execution methods that will cause the least possible pain and suffering.

[180] American College of Physicians and Human Rights Watch, Breach of Trust, p. 32. The
AMA distinguishes between pronouncing death, which they consider unethical,
and certifying death, which is acceptable. The difference is that the former
involves monitoring the condition of the prisoner during the execution to
determine at which point the individual has died; whereas certifying is
confirming the individual is dead after another has pronounced it. Council on
Ethical And Judicial Affairs, Physician Participation in Capital Punishment, Journal
of the American Medical Association, 1993, p. 270, 365-368.

[181] American College of Physicians and Human Rights Watch, Breach of Trust, p. 32.

[195] For
examples of corrections medical staff refusing to participate, see: American College of Physicians and Human Rights Watch, Breach of Trust, p.26-29.

[196]
Interview with Atherton. EMTs apparently are not subject to the same ethical
restrictions as physicians.

[197] Georgia House Bill 57 (2006) proposes:
Participation in any execution of any convicted person carried out under this
article shall not be the subject of any licensure challenge, suspension, or
revocation for any physician or medical professional licensed in the State of Georgia." (copy on file with Human Rights Watch). Oklahoma House Bill 2660 proposes:
No licensing entity, board, commission, association, or agency shall file,
attempt to file, initiate a proceeding, or take any action to revoke, suspend,
or deny a license to any person authorized to operate as a professional in the
State of Oklahoma, for the reason that the person participated in any manner in
the execution process as required or authorized by law or the Director of the
Department of Corrections (copy on file with Human Rights Watch).